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There’s something that really bothers Stanford psychiatry professor Keith Humphreys. When he thinks of all the years he spends training the next generation of psychiatrists, the enormous investment in medical school and residency, he wants them to devote that education to taking care of people with serious mental illness.

But many of them instead set up a private practice, where they can charge $400 an hour in cash to help people who Humphreys calls “the worried well” –- people who enjoy the self-exploration of therapy but do not necessarily have a mental health problem.

“A minute I spend training that person is a minute of my life wasted,” Humphreys says. “That very well-trained person should be taking care of very, very troubled people. When they don’t, everyone who needs that care loses out.”

Humphreys says this trend of mental health clinicians shunning the health insurance industry and decamping to the cash market dates back 70 years, to the end of World War II.

In 1946, the majority of veterans cared for by what was then called the Veterans Administration were mental health patients, Humphreys says. But there weren’t enough mental health providers to take care of them. So the VA partnered with several medical schools, including Stanford where Humphreys teaches, to train mental health professionals.

Those schools started turning out hundreds and hundreds of psychologists a year. The expansion dovetailed with soaring American affluence — and soaring American interest in self-exploration.

Having a psychoanalyst became “a sort of status symbol,” Humphreys says.

A lot of psychologists who were trained to work in the public sector saw a better financial opportunity and jumped ship. They hung shingles and started their own private practices where they could charge wealthy people much higher rates.

“When you put in a free market in a society where people were very interested in self-exploration, a lot of them went out and did their own thing,” Humphreys says.

Stanford psychiatry professor Keith Humphreys
Stanford psychiatry professor Keith Humphreys (Courtesy: Keith Humphreys)

The reason this was possible is because of how the overall U.S. health care system was established, Humphreys says. Most people got their health insurance through work. Employers competed with each other for the best employees by offering better benefits.

So the standards for coverage developed over time in a piecemeal, haphazard way.

As health policy evolved, mental health benefits continuously lagged, Humphreys says. Coverage for mental health treatments or hospitalizations was meager or nonexistent.

“We don’t seem to have this problem with cardiology or oncology,” Humphreys says. “You don’t see people lining up to pay cash for those services because the benefits are so low.”

This wouldn’t happen in places that have single-payer health systems, like Canada, Humphreys says, because all the health care payments are controlled by the government. Mental health care was baked into that system earlier on.

As a result, people in Canada with more severe mental illness are more likely to get services, according to a study published in the New England Journal of Medicine.

That’s not the case in the U.S. People with less serious mental health conditions get more services here. Humphreys says it’s mainly wealthy people who fall into the worried well category, who are consuming psychotherapy.

“If it’s a market where you pretty much have to pay for yourself, the rich are always going to win,” he says.

The growing workforce of psychiatrists, psychologists, marriage and family therapists, and licensed social workers has responded to that market demand.

And not just because it’s better money. Treating high-functioning professionals in a private office is a lot less stressful than doing rounds on a psychiatric ward of a public hospital.

“It’s understandable why someone would say this is really demanding,” Humphreys says. “For my own well-being or professional satisfaction, I’m going to stop doing this and move into doing outpatient psychotherapy with executives from Google who have angst. My salary goes up dramatically and my work is much, much easier.”

Especially in affluent places like the Bay Area, this creates a divide, a culture of mental health haves and have-nots. Mental health clinicians don’t need to participate in the health care system or take insurance to keep their schedules full — making it harder and harder for people of lower income to find a therapist.

“That’s why you can have a lot of mental health professionals in an area, but still have a shortage of care for people in need,” Humphreys adds. “The person who’s hurt is the person who’s suicidal, maybe they’re horribly addicted to OxyContin or their child is showing signs of bipolar disorder, and they can’t find somebody to take their insurance. It’s unjust.”

Mental health advocates have worked to shift this balance, passing the Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act in 2010. Together, those laws require health plans to offer mental health coverage on par with other medical coverage.

But so far, it hasn’t put a dent in the cash market for mental health. Humphreys says given the nature of mental health care and the American obsession with self-improvement, the cash market will be here to stay.

“Accessing mental health care is often pleasurable and enjoyable, and accessing a lot of other health care isn’t,” Humphreys says. “I mean, who goes to the dentist for fun?”

How Therapy Became A Hobby of the Wealthy – Rather Than A Necessity for the Mentally Ill 2 June,2016April Dembosky

  • George Grunwald

    When I studied for my MSW at Berkeley in the late 1960’s, I had decently paid internships both years; the first paid by the VA, the second by NIH. It was unheard of for an social service agency to offer unpaid internships Many of my fellow students had substantial scholarships provided by the State of California. these grants covered tuition and fees. I was one of the very few students who took out a student loan, because of extraordinary medical expenses. It was about $200-$300, which I paid off within six months of graduation.

    A year after I graduated I bought a house which cost 1.5 times my annual salary.

    I’m retired now, but I was able to support a family — very modestly, to be sure — providing treatment to what are now called underserved populations. I never made a lot of money, but we always had food on the table and a roof over our heads that was ours and has been paid off for years. I was able to live my ideals.

    Now, students leave graduate programs with as much as $100,000 debt. The median price of a house in the Bay Area is 15-20 times a typical starting salary in human services. They may have ideals to begin with , but they have to make a living. It makes perfect sense for them to go where the money is.

    This article suggests that the fault lies with greedy insurance companies or with mental health clinicians looking for the easy big bucks. I would suggest that the reason mental health services for the mentally ill are starved is the decision this country made years ago to stop provide adequate funding these services.

    • Wahoo Q. Delirious

      There is a tone to this piece that strikes me wrong – and it is set in the title.
      I am a psychiatrist in private practice, and I provide a spectrum of services and work with all socio-economic levels. As is strongly encouraged in our training, I also have had extensive psychotherapy myself. I have struggled with the observation that the sickest patients tend to not get the best care available – especially psychotherapy services when needed and indicated.
      Therapy is most definitely NOT a “hobby,” nor an “enjoyable” experience [at least not in the moment]. It is an extremely helpful modality of treatment for many forms of human suffering. People who are “wealthy” for the most part don’t just go to therapy like it’s some kind of spa treatment – most of the cash-paying clients I have treated have psychic pain that is quite real and quite terrible.
      I agree with other commentators – the main problem is a broken and underfunded mental health system that gets worse over time. Mental health treatment is still poorly understood and stigmatized in our culture. Those with serious mental illness – and the ones who treat them! – are marginalized in our culture. Let’s not target mental health care providers for making prudent career decisions, nor “the wealthy” for seeking treatment. Unless, of course, they are also the ones behind the under-funding of the public treatment system [and there may be some overlap there] – in that case, then fire away! for THAT.

  • Su

    I’ve got to say, I don’t go to therapy for fun. I go for long, anxiety-provoking exposures. Where is this “enjoyable” therapy? I want to be a part of this. 😛

  • notmike64

    I pay five dollars a session…

  • This issue is complex enough that anyone can highlight a piece of it to make a point. Yes, it’s true that insurance panels are often full of unavailable doctors/therapists, and that the companies limit access to services, or their duration, to save costs. It is illegal for them to do this fraudulently, and they can be reported if they do. However, limits of some sort are inevitable; there is no such thing as a 3rd party blank check. Mental health concerns and their treatments are notoriously hard to quantify, but a line must be drawn somewhere. Whether insurance is private or public or eventually “single-payer” this will always be true. Those suffering a thought or mood disorder rendering them unable to work should obviously receive coverage on par with any other illness or injury. For longstanding relationship conflicts or not being fully satisfied with life, it’s much less clear.

    On the provider side, many of us avoid insurance contracts in order to offer the highest quality care we can, without these externally imposed constraints. As it happens, direct pay also means less paperwork and higher fees — although nowhere near $400/hr as stated in the article — a combination that’s hard to turn down. In order to avoid being elitist, many of us either see a subset of patients at a lower sliding-scale fee, or accept some Medicare patients. Medicare covers the chronically disabled as well as elderly, and pays roughly 60% of my usual fee. With increasing requirements by Medicare for electronic prescribing, quality-assurance measures, and the like, solo practitioners like me are less and less likely to participate if we have alternatives. As the years go on, I’m increasingly inclined to manage my own balance of high quality care and access, and not have it done for me in an ham-handed way by Medicare or anyone else.

    Remember when a middle class family could own a home, send kids to college, maybe have two cars? They could also afford weekly private psychotherapy at $35/hr. But that was in 1970. Adjusting for inflation, $35 then is $215 now. That such “luxuries” seem unaffordable now (but an $800 smartphone and pricey service plan doesn’t) requires an economic analysis that goes well beyond mental health care. Therapy isn’t, or at least shouldn’t be, a “hobby for the wealthy.” I have cash-paying patients with severe misery and major life disruptions. I had a patient suicide last year. At the same time, it isn’t a cheap commodity. My patients pay good money and I expect them to stop when they get what they came for. As I tell them, I aim to make myself obsolete in their lives. But before that time comes, I offer experienced mind-body consultation on terms acceptable to the two of us in the room. If there’s a better model of mental health care, I’m all ears.

  • Emu Sanders

    I revcd excellent training at the National Center for PTSD in Menlo Park and worked for VAPA for over 5 years. Despite the local and national conversation about he severe MH needs of our Veterans no attempts were made to improve access to MH for those Vets in Santa Cruz County. In addition the VA chose to provide no office space to the team of clinical SW’s providing care to the most severley ill and challenged; those veterans experiencing chronic homelessness. These Vets are often un-welome in the Capitola Clinic and in other VA clinics. Without the apropriate resources and a greater tolerance for serving ALL Veterans this work was extremely difficult for both the Veterans and the Staff.
    With many many many other options for behavioral health clinicians why wold one stay in such a broken, substandard, and uncomfortable situation?

  • john moyer, M. Ed.

    Please. Who goes to a therapist for fun? There are cheaper and more exciting forms of entertainment. The fact is we don’t need more psychiatrists. We need mental health workers with a few years of graduate work that can do just as well as a psychiatrist with a medical degree. Then they won’t feel the pressure to pay off the $250k school loans that psychiatrists rack up, and you can pay them half as much in facilities that aren’t overcrowded and meat-grinders to work in.


April Dembosky

April Dembosky is the health reporter for The California Report and KQED News. She covers health policy and public health, and has reported extensively on the economics of health care, the roll-out of the Affordable Care Act in California, mental health and end-of-life issues.

Her work is regularly rebroadcast on NPR and has been recognized with awards from the Society for Professional Journalists (for sports reporting), and the Association of Health Care Journalists (for a story about pediatric hospice). Her hour-long radio documentary about home funerals won the Best New Artist award from the Third Coast International Audio Festival in 2009.

April occasionally moonlights on the arts beat, covering music and dance. Her story about the first symphony orchestra at Burning Man won the award for Best Use of Sound from the Public Radio News Directors Inc.

Before joining KQED in 2013, April covered technology and Silicon Valley for The Financial Times, and freelanced for Marketplace and The New York Times. She is a graduate of the University of California at Berkeley Graduate School of Journalism and Smith College.